Iliopectineal Ligament As an Important Landmark in Ilioinguinal Approach of the Anterior Acetabulum

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International Journal of Anatomy and Research, Int J Anat Res 2019, Vol 7(3.3):6976-82. ISSN 2321-4287 Original Research Article DOI: https://dx.doi.org/10.16965/ijar.2019.274 ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY Ayman Ahmed Khanfour *1, Ashraf Ahmed Khanfour 2. *1 Anatomy department Faculty of Medicine, Alexandria University, Egypt. 2 Chairman of Orthopaedic surgery department Damanhour National Medical Institute Egypt. ABSTRACT

Background: The iliopectineal ligament is the most stout anterior part of the iliopectineal membrane. It separates “lacuna musculorum” laterally from “lacuna vasorum” medially. This ligament is an important guide in the safe anterior approach to the acetabulum. Aim of the work: To study the detailed anatomy of the iliopectineal ligament demonstrating its importance as a surgical landmark in the anterior approach to the acetabulum. Material and methods: The material of this work included eight adult formalin preserved cadavers. Dissection of the groin was done for each cadaver in supine position with exposure of the inguinal ligament. The iliopectineal ligament and the three surgical windows in the anterior approach to the acetabulum were revealed. Results: Results described the detailed morphological anatomy of the iliopectineal ligament as regard its thickness, attachments and variations in its thickness. The study also revealed important anatomical measurements in relation to the inguinal ligament. The distance between the anterior superior iliac spine (ASIS) to the pubic tubercle ranged from 6.7 to 10.1 cm with a mean value of 8.31±1.3. The distance between the anterior superior iliac spine (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament ranged from 1.55 to 1.92 cm with a mean value of 1.78±0.15. Conclusion: The iliopectineal ligament detailed morphology and attachments are crucial when planning to do anterior approach of the acetabulum to decrease incidence of iatrogenic injury to the femoral vessels. KEY WORDS: Iliopsoas fascia - Iliopectineal membrane - Iliopectineal ligament - Inguinal ligament -Anterior acetabular approach. Address for Correspondence: Ayman Ahmed Khanfour: Assistant professor in the human Anatomy and Embryology department, Faculty of Medicine, University of Alexandria, Egypt. Mobile: 00201223815866. E-Mail: [email protected] Access this Article online Journal Information Quick Response code International Journal of Anatomy and Research ICV for 2016 ISSN (E) 2321-4287 | ISSN (P) 2321-8967 90.30 https://www.ijmhr.org/ijar.htm DOI-Prefix: https://dx.doi.org/10.16965/ijar Article Information Received: 17 Jul 2019 Accepted: 19 Aug 2019 Peer Review: 17 Jul 2019 Published (O): 05 Sep 2019 DOI: 10.16965/ijar.2019.274 Revised: None Published (P): 05 Sep 2019

INTRODUCTION considered as a continuation of the transversus The iliopsoas fascia is the mother name given abdominis fascia. It is thinner anteriorly but to all the relatively dense layer of fascia that progressively becomes thicker medially [1,2]. covers the anteromedial aspect of iliopsoas The iliopectineal membrane is the relatively muscle as a whole. It tethers the iliopsoas denser medial part of this iliopsoas fascia on muscle, femoral nerve and lateral cutaneous its anteromedial surface run the great femoral nerve of the thigh to the iliac fossa. It could be vessels. Consequently, the most anterior part of

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6976 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. this iliopectineal membrane forms an even more (Fig. 1). The skin and subcutaneous tissues along stout ligament like structure that is called the the proposed line of incision were deepened up iliopectineal ligament which subdivides the to the aponeurosis of the external oblique space deep to the inguinal ligament into a muscle. At the end, the ilioinguinal approach was lateral muscular lacunae and a medial vascular completed by developing three anatomical lacunae [3]. windows (Fig. 2). The 1st window was devel- Surgical treatment of anterior acetabular oped by subperiosteal dissection of the iliac fractures entails good anatomic reduction with crest and iliac fossa elevating the insertion of restoring hip congruency [4,5]. This necessi- the anterior abdominal wall muscles together tates adequate anterior exposure using the well- with the origin of the iliacus in continuity up to known ilioinguinal approach in which isolation the sacroiliac joint posteriorly and the pelvic of the iliopectineal ligament is a crucial step [6]. brim anteriorly. The 2nd window starts by opening the anterior wall of the inguinal canal Sharp cutting of this iliopectineal ligament as a by incising the external oblique aponeurosis crucial step in the ilioinguinal approach to from the anterior superior iliac spine (ASIS) up mobilize the iliopsoas muscle to permit good to the midline 1 cm above the superficial exposure, reduction and fixation of anterior inguinal ring. The spermatic cord or the round acetabular fractures located anyway from the ligament was retracted by a rubber sling anterior aspect of the sacroiliac joint up to the medially. pubic symphysis, including exposure of the quadrilateral surface. Unfortunately, great Then, the posterior wall of the inguinal canal is femoral vessels (artery and vein) lie directly on opened by sharp incising the inguinal ligament the anteromedial surface of this ligament, into two equal superior and inferior flaps, putting them at high risk for iatrogenic injury exposing the subinguinal region posterior to the [7,8]. Limited sources about the detailed inguinal ligament. This region is subdivided into morphological anatomy about this important two spaces; the “lacuna vasorum” lies medially iliopectineal membrane and ligament was the and the “lacuna musculosum” laterally major driving force for this study. separated by the iliopectineal ligament that is the issue of this study. Now the 2nd window can Aim of the work: The aim of this work was to be developed by retracting the “lacuna study the detailed anatomy of the iliopectineal musculosum” containing the iliopsoas, the ligament demonstrating its importance as a femoral nerve and the lateral cutaneous nerve surgical landmark in the anterior approach to of the thigh laterally, and the “Lacuna vasorum” the acetabulum. And using it together with spe- containing the external iliac vessels medially cial surgical tactics to prevent iatrogenic injury with the iliopectineal ligament. At this stage, to great femoral vessels. the iliopectineal membrane and ligament MATERIALS AND METHODS become fully isolated and their detailed The material of this work included eight adult anatomical morphology was studied as regards formalin preserved cadavers obtained from the their attachment, thickness, point of its hitch Dissecting Room of Anatomy Department, hike of the iliopectineal ligament to the inguinal Faculty of Medicine, Alexandria University. ligament, and their relation to the vital In this study, the ilioinguinal approach that was structures especially great femoral vessels. In originally described in the literature of Emile the original description of this approach, the Letournel in 1993 was simulated in all of the iliopectineal ligament and membrane were cases included in this study [7]. The cadaveric completely incised in an anteroposterior position was supine with exposure of the groin direction up to the pelvic brim in order to freely area. An incision was done extending along the mobilize the Iliopsoas muscle developing the 3rd anterior two-thirds of the iliac crest, passing window by retracting the slung lacuna vasorum through the anterior superior iliac spine (ASIS) laterally and the spermatic cord medially. At this then continued to the midline, approximately step, a detailed morphological anatomy of the two fingerbreadths above the pubic symphysis iliopectineal membrane and ligament took place.

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6977 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. Fig. 1: A photograph of a right side groin showing the analysis was done using Statistical Package for line of incision starting from the anterior two-thirds of Social Sciences (SPSS/version 20) software. the iliac crest (I), passing through the anterior superior iliac spine (ASIS) then continues to the midline, approxi- Arthematic mean, standard deviation were used mately two fingerbreadths above the pubic symphysis to the numerical measurements. To find the (SP). association between two variables, Spearman correlation coefficient test was used and the level of significant was 0.05. To predict the distance of the blending point of iliopectineal ligament to inguinal ligament, the multiple logestic regression analysis was done to predict the equation. RESULTS Morphological findings: The investing fascia of the iliopsoas was found to invest the iliopsoas muscle together with the femoral nerve and the lateral cutaneous nerve of the thigh. It forms a thin membrane anteriorly, then it becomes thicker as we go medially to form the iliopectineal membrane. Again, the most anterior part of the iliopectineal membrane Fig. 2: A photograph of a right groin showing the three becomes even thicker forming the iliopectineal windows. The left of the photograph showing the first window (1) while the right part of the photograph ligament (Fig. 3). The attachments of the showing the second and third windows (2) and (3) iliopsoas fascia as a whole are: laterally to the respectively. (C: Iliac crest - M: Iliopsoas muscle - A: iliac crest, medially to the pelvic brim, posteri- External iliac artery – V: External iliac vein – S: Spermatic orly to the sacrum and anteriorly attached to the cord). inguinal ligament. So, the iliopectineal ligament is the stoutest part of this facia at all. It runs antero-laterally in an oblique inclination from the “iliopectineal eminence” to hitch hick the inguinal ligament approximately at the region nearly at the junc- tion between its lateral third and medial two thirds. Fig 4 Measurements: Anatomical measurements involved measure- ment of the distance between the anterior a. Distance between the anterior superior iliac superior iliac spine (ASIS) to the pubic tubercle spine (ASIS) to the pubic tubercle. Fig 5 (Tab. 1) and the distance between the anterior superior The distance between the anterior superior iliac iliac spine (ASIS) to the blending point of the spine (ASIS) to the pubic tubercle ranged from iliopectineal ligament to the inguinal ligament. 6.7 to 10.1 cm with a mean value of 8.31±1.3 These measurements were done using manual b. Distance between the anterior superior iliac Smith Vernier caliber. spine (ASIS) to the blending point of the In one specimen, in order to study the morphol- iliopectineal ligament to the inguinal ligament. ogy of all the investing iliopsoas fascia as a Fig 4 (Table 1) whole, the anterior abdominal wall and all The distance between the anterior superior iliac abdominal viscera in front of the ilacus muscle spine (ASIS) to the blending point of the ili- with its fascia were removed. opectineal ligament to the inguinal ligament Statistical analysis: The Data was collected and ranged from 1.55 to 1.92 cm with a mean value entered into the personal computer. Statistical of 1.78±0.15

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6978 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. The equation of prediction of the distance Fig. 5: A photograph of a right groin showing the relation between (ASIS) to the blending point of the between the length of the inguinal ligament (I) and the iliopectineal ligament to the inguinal ligament.in blending point (arrow) of the iliopectineal ligament (P) to the inguinal ligament (I). (ASIS: Anterior superior iliac relation to the total length of inguinal ligament spine - A: External iliac artery – V: External iliac vein – T: was: Pubic tubercle – M: iliopsoas muscle) Blending point of iliopectineal ligament to inguinal ligament = 0.940 + (0.101* Inguinal ligament) With accuracy = 97.0%. Fig. 3: A photograph of a right side cadaver showing the morphology of the iliopsoas fascia after removal of the anterior abdominal wall and viscera. The iliopsoas fascia (IP) seen thin and transparent anteriorly up to the extent that part of it was accidentally removed during dissection (R). It becomes more opaque i.e thicker medially (arrows) forming iliopectineal membrane. (C: Iliac crest – ASIS: Anterior superior iliac spine - A: External iliac artery – V: External iliac vein).

Table 1: Correlation between the total length of the inguinal ligament and the distance between (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament in cm.

Total length of the Distance between (ASIS) to the blending inguinal ligament point of the iliopectineal ligament to the in cm inguinal ligament in cm Range 6.7-10.1 1.55-1.92 Mean 8.31 1.78 S.D. 1.36 0.15

spearman correlation 0.95 coefficient (r)

P value 0.001* Fig. 4: A photograph of a right groin showing the point of hitch hick (H) of iliopectineal ligament (P) to the inguinal Table 2: Multiple logestic regression analysis to predict ligament (I). (ASIS: Anterior superior iliac spine - A: the distance between (ASIS) to the blending point of the External iliac artery – V: External iliac vein – L: Lateral iliopectineal ligament to the inguinal ligament from the cutaneous nerve of thigh) total length of the inguinal ligament. Model Sum of Squares dfMean Square F Sig. Regression 0.133 1 0.133 55.028 0 Residual 0.014 6 0.002 Total 0.147 7 a. Dependent Variable: Distance between (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament. Coefficientsa

Unstandardized Standardized Model Coefficients Coefficients t Sig. B Std. Error Beta (Constant) 0.94 0.115 8.2 0 1 Inguinal ligament 0.101 0.014 0.95 7.418 0 a. Dependent Variable: Distance between (ASIS) to the blending point of the iliopectineal ligament to the inguinal ligament.

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6979 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. DISCUSSION displaced anterior acetabular fractures through Management of acetabular fractures involving a longitudinal pararectus incision. Although in the anterior all and column is challenging [9]. their study proved a satisfactory improvement Although nowadays there are many surgical in instrumentation, fracture reduction, and approaches invented to access the anterior fixation, a potential disadvantage of this acetabular wall and column, still the ilioinguinal approach might be the relatively high risk of approach is considered the state of the art entering the peritoneum and vascular injury [9]. approach for the open surgical reduction and Chen K et al in 2018 reported that the single internal fixation of the anterior fractures of the incision used by Keel MJ et al is far cephalad acetabulum [10]. In this approach, dissection from the anterior bonny pelvis which is the around the femoral vessels in its middle target site for the surgery. They described a window constitutes a high risk for their similar approach but it was more caudate to the iatrogenic injury that necessitates special original ilioinguinal approach, that they called caution [11]. Knowing that these vessels lie “supra-ilioinguinal approach”. They reported directly in a close relation to the anteromedial easier instrumentation, reduction and fixation surface of the iliopectineal membrane and of fractures especially that exiting the iliac crest. ligament, a detailed study of its morphological And low risk for peritoneal injury [15]. So, nowa- anatomy together with carrying out special tacts days there is resurgence again to the ilioinguinal during surgical dissection can reduce this risk approach [10]. significantly [1,10]. The aforementioned discussion would highlight This Ilioinguinal approach was first mentioned the necessity of studding in depth the surgical by Letournel in 1961 as an extra-pelvic, extra- anatomy and morphology of the iliopectineal peritoneal, trans-inguinal canal approach membrane and ligament as an important [12,13]. it did not became fully recognized and landmark for avoiding injury to the great applied on a wide scale except after publishing femoral vessels. On reviewing the literature, we this author cadaveric study on that approach in did not come through any paper discussing in 1993 demonstrating the clear surgical develop- detail the surgical anatomy and morphology of ment of the 3 working windows. Unfortunately, this ligament. he did not pay any attention to describe the Fig. 6: A diagrammatic representation of inside axio- surgical anatomic morphology of the ili- caudal view of right groin showing the relation between inguinal ligament and the blending point of the opectineal ligament, on which this approach is iliopectineal ligament. (P) to the inguinal ligament (I). muchly depends on in a clear practical way [7]. (ASIS: Anterior superior iliac spine - A: External iliac Recently, many recent approaches were artery – V: External iliac vein – T: Pubic tubercle – M: published, all share the idea of how to avoid iliopsoas muscle) dissection in this second dangerous window to avoid iatrogenic injury to femoral great vessels. Of these, Cole JD et al in 1994 described a limited intrapelvic extraperitoneal approach that was called modified Stoppa anterior intrapelvic extra-peritoneal approach [14]. The approach involves a transverse skin incision 2 cm above the pubic symphysis followed by a midline split of the rectus abdominis, with or without iliac crest incision mimicking the first window of the ilioinguinal approach. But still dissection and surgery are carried out beneath and in close relation to the great femoral vessels [14]. Keel M J et al in 2012 described As regards the iliopectineal membrane is the a new anterior intrapelvic, extraperitoneal thickened medial part of the investing approach for the surgical management of iliopsoas fascia, it has a bonny origin starts from

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6980 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. the pectineal eminence anteriorly to the pelvic Weinstein, S. L. et al [18] and Yorgancigil, H. brim posteriorly. Again, The Iliopectineal liga- el al [19]. ment (known also as iliopectineal band or arch) CONCLUSION is the most thickened anterior part of this Iliopectineal ligament is an important surgical iliopectineal membrane. This band takes origin anatomical landmark for orthopaedic surgeons from the pectineal eminence and hitch hick the practicing acetabular or hip surgery through inguinal ligament at a point ranging from 1.55 ilioinguinal anterior pelvic approach. This is to 1.92 cm from the (ASIS) with a mean value of because it is a very tough ligament that acts as 1.78±0.15 (Fig. 6 Diagram). It separates the both landmark and safeguard protecting the subinguinal space into the corpus musculosum femoral vessels ‘that lie directly on its from the corpus vasculosum. this was also anteromedial surface’ during extrapelvic, demonstrated by Wang P et. al in 2016 [11]. extraperitoneal dissection to the bony pelvis and This was found to be useful for the orthopaedic acetabulum. Good isolation of this ligament both surgeon practicing the ilioinguinal approach to antromedial and posterolateral surfaces is the anterior acetabulum. Where it is advisable mandatory to enable isolation and protection of to the surgeon to start the step of incising the these vessels before its cutting under clear inguinal ligament in order to reach the parietal vision. pelvis on the most lateral part near to the ASIS ABBREVIATIONS and then go by the incision medially until reaching the hitch hick point of the iliopectineal ASIS: Anterior Superior Iliac Spine ligament to it. At that point, to continue safe Conflicts of Interests: None dissection as regards the femoral vessels, the REFERENCES surgeon is advised to slip his finger in the cleavage space between the iliopsoas muscle [1]. Teague DC. Inguinal anatomy and retropubicvascular laterally and the posterolateral aspect of the hazards of the ilioinguinal approach. Operative Techniques in Orthopaedics. 1997;7(3):175-83. iliopectineal ligament medially, this ligament [2]. Basinger H, Hogg JP. Anatomy, Abdomen and Pelvis, now acts now as an important anatomical and Femoral Triangle. StatPearls. Treasure Island (FL): surgical landmark at this stage as the femoral StatPearls Publishing StatPearls Publishing LLC.; vessels are directly located over its 2019. anteromedial surface. On doing so, the femo- [3]. Lew V, Kang M. Anatomy, Pelvis, Femoral Sheath. StatPearls. Treasure Island (FL): StatPearls Publish- ral vessels are now clearly located and safely ing StatPearls Publishing LLC.; 2018. slung by a soft rubber band and retracted medi- [4]. Gansslen A, Grechenig ST, Nerlich M, Muller M, ally before completing the development of the Grechenig W. Standard Approaches to the Acetabu- 2nd window by incising this ligament in an lum Part 2: Ilioinguinal Approach. Acta chirurgiae anteroposterior direction to enable the surgeon orthopaedicae et traumatologiae Cechoslovaca. 2016;83(4):217-22. completing his approach to bonny pelvis by [5]. Akgul T, Coskun O, Korkmaz M, Gurses IA, Sen C, mobilizing this iliopsoas membrane. Gayretli O. A Minimally Invasive Technique Using a Another important value of the iliopectineal Modified Stoppa Approach for Periacetabular Osteotomy: A Preliminary Cadaveric Study. Indian ligament arose during the surgical treatment of journal of orthopaedics. 2017;51(6):687-91. developmental dislocation of the hip, where the [6]. Abo-Elsoud M, Radwan YA, Gobba M, Sadek F. Short- paediatric orthopaedic surgeons during practis- segment fixation through a limited ilioinguinal ap- ing open reduction for congenital dislocation of proach for treating anterior acetabular fractures: a the hip, mobilization of the iliopsoas muscle by historical-control study. International orthopaedics. 2014;38(7):1469-75. internal rotating it on itself at the pelvic prim to [7]. Letournel E. The treatment of acetabular fractures release its underneath contracted tendon is an through the ilioinguinal approach. Clinical ortho- important step. In this step, the iliopectineal paedics and related research. 1993(292):62-76. ligaments stands as a safeguard against [8]. Wang XJ, Lu L, Zhang ZH, Su YX, Guo XS, Wei XC, et al. reaching the femoral vessels and preventing Ilioinguinal approach versus Stoppa approach for open reduction and internal fixation in the treat- their iatrogenic injury. These facts were ment of displaced acetabular fractures: A system- supported also by Glorion, C. et al (16, 17) , atic review and meta-analysis. Chinese journal of Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6981 Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. traumatology = Zhonghua chuang shang za zhi. [15]. Chen K, Ji Y, Huang Z, Navinduth R, Yang F, Sun T, et al. 2017;20(4):229-34. Single Modified Ilioinguinal Approach for the Treat- [9]. Keel MJ, Ecker TM, Cullmann JL, Bergmann M, Bonel ment of Acetabular Fractures Involving Both Col- HM, Buchler L, et al. The Pararectus approach for umns. Journal of orthopaedic trauma. anterior intrapelvic management of acetabular frac- 2018;32(11):e428-e34. tures: an anatomical study and clinical evaluation. [16]. Glorion C. Surgical reduction of congenital hip dis- The Journal of bone and joint surgery British vol- location. Orthopaedics & traumatology, surgery & ume. 2012;94(3):405-11. research : OTSR. 2018;104(1s):S147-s57. [10].Tosounidis TH, Giannoudis VP, Kanakaris NK, [17]. Thawrani D, Sucato DJ, Podeszwa DA, DeLaRocha A. Giannoudis PV. The Ilioinguinal Approach: State of Complications associated with the Bernese the Art. JBJS essential surgical techniques. periacetabular osteotomy for hip dysplasia in ado- 2018;8(2):e19. lescents. The Journal of bone and joint surgery [11]. Wang P, Zhu X, Xu P, Zhang Y, Wang L, Liu X, et al. American volume. 2010;92(8):1707-14. Modified ilioinguinal approach in combined surgi- [18]. Weinstein SL, Dolan LA, Morcuende JA. The 2018 cal exposures for displaced acetabular fractures Nicholas Andry Award: The Evidence Base for the involving two columns. SpringerPlus. Treatment of Developmental Dysplasia of the Hip: 2016;5(1):1602. The Iowa Contribution. Clinical orthopaedics and [12]. Letournel E. Fractures of the acetabulum. A study of related research. 2018;476(5):1043-51. a series of 75 cases. 1961. Clinical orthopaedics [19]. Yorgancigil H, Aslan A. Comparison of the clinical and related research. 1994(305):5-9. and radiological outcomes of open reduction via [13]. Judet R, Judet J, Letournel E. Fractures of the ac- medial and anterior approach in devleopmental etabulum: classification and surgical approaches dysplasia of the hip. Eklem hastaliklari ve cerrahisi for open reduction. Preliminary report. The Journal = Joint diseases & related surgery. 2016;27(2):74- of bone and joint surgery American volume. 80. 1964;46:1615-46. [14]. Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clinical orthopaedics and related research. 1994(305):112-23.

How to cite this article: Ayman Ahmed Khanfour, Ashraf Ahmed Khanfour. ILIOPECTINEAL LIGAMENT AS AN IMPORTANT LANDMARK IN ILIOINGUINAL APPROACH OF THE ANTERIOR ACETABULUM: A CADAVERIC MORPHOLOGIC STUDY. Int J Anat Res 2019;7(3.3):6976-6982. DOI: 10.16965/ijar.2019.274

Int J Anat Res 2019, 7(3.3):6976-82. ISSN 2321-4287 6982